High-risk individuals with substance use disorder (SUD), especially those who are justice-involved or homeless, have poor outcomes across a range of health indicators, including mortality. Better care requires multiple entities working in concert to share time-sensitive information, identify and prioritize the highest risk persons, and coordinate care across sectors. We propose to build and test a replicable, extensible and evaluable clinical support and analytics solution that meets the following specific aims: SA 1: Establish project scope and governance for data integration across sectors SA1.1 Convene stakeholders to design shared tools to improve outcomes SA1.2 Leverage existing governance structures to ensure extensibility and alignment with broad community/clinical data-sharing efforts SA 2: Create a shared language and systematic approach to risk assessment, care coordination and monitoring cross-sector use of services and costs SA2.1 Partner with stakeholders, including patients, to identify information needs SA2.2 Employ human-centered design principles and Lean methods for tool/dashboard design SA2.3 Elaborate requirements for EHR-supported workflows/dashboards SA2.4 Design and build EHR accessible tools for sharing data with capacity to integrate with a community-wide, social health information exchange SA 3: Deploy tools across sectors and assess impact on risk assessment, care coordination and performance monitoring workflows SA 3.1 Use formative evaluation to gauge adoption, reach and extensibility SA 3.2 Demonstrate the feasibility of summative evaluation to measure ROI SA 4: Provide a road map for sustaining and extending EHR tool implementation SA4.1 Partner with Colorado stakeholders to design next phase efforts SA4.2 Provide a tool kit of extensibility recommendations for state-wide interoperable cross-sector care coordination, leveraging data-sharing resources We will meet these aims and optimize data integration within a common EHR platform (i.e., Epic) through a Denver-based collaboration that includes an integrated delivery system, EHR-agnostic health information exchange, a unit that combines local public health functions with advanced informatics, and homeless services provider.